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OBJECTIVE: To compare body mass index (BMI) and waist and hip circumference in early puberty (10.8 years in girls and 11.8 years in boys) among offspring of preeclamptic and normotensive pregnancies. DESIGN: Population based follow-up study. METHODS: Anthropometry measured in early puberty in 91 girls and 92 boys of preeclamptic pregnancies, and in 194 girls and 166 boys of normotensive pregnancies, with similar anthropometric measures among mothers, performed at the beginning of the index pregnancy, and at follow-up, when their offspring were in early puberty. RESULTS: Among girls, the preeclampsia group had higher body mass (BMI 18.3 kg/m(2) vs 17.5 kg/m(2), p = 0.01) and larger waist circumference (63.7 cm vs 61.6 cm, p = 0.05) compared to the normotensive group, but the differences were restricted to the offspring of mothers with a high body mass (BMI >30 kg/m(2)). Among boys, we observed no differences in anthropometric measurements between groups. CONCLUSIONS: The higher BMI and larger waist of daughters of women with preeclampsia was only present if their mothers were obese. These results suggest that preeclampsia in obese women may lead to a distinct disadvantage in body size for their daughters in early puberty.

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Women born after pre-eclamptic pregnancies have been reported to be at reduced risk of breast cancer as adults, because of reduced intrauterine oestrogen influence on breast tissue; high levels of alpha-foetoprotein (a glycoprotein with anti-oestrogenic properties), however, could also be important. In severe pre-eclampsia, placental function and foetal growth are reduced, and umbilical cord plasma levels of alpha-foetoprotein could reflect the underlying processes. Umbilical cord blood was collected in 12804 consecutive deliveries. Among 307 pregnancies with clinical pre-eclampsia, 66 singleton pregnancies were identified as clinically severe, and 610 singleton pregnancies were selected as controls. Oestradiol and alpha-foetoprotein were measured from umbilical plasma, and birth weight was standardized as the ratio between the observed and expected birth weight, adjusted for differences in gestation length and offspring sex. Cord plasma levels of alpha-foetoprotein were significantly higher in severe pre-eclampsia than controls (P<0.01) after adjustment for gestational age and birth weight. For oestradiol, there was no difference in cord plasma levels between the severe pre-eclampsia group and controls, after adjustment for length of gestation and birth weight. These results suggest that an anti-oestrogenic effect associated with pre-eclampsia may be mediated through high levels of alpha-foetoprotein rather than low levels of oestradiol.

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Approximately 20% of women in industrialized countries have iron deficiency in pregnancy. This article focuses on the diagnostic problem of anemia and iron deficiency and discusses different strategies for iron supplementation in pregnancy. S-ferritin is commonly used to diagnose empty iron stores and is considered useful early in pregnancy as a diagnostic tool. Mean cellular volume (MCV), s-Fe and erythrocyte distribution width is too unspecific. Serum transferrin receptor (sTfR) is a relatively novel promising indicator of iron deficiency. Iron demands of the pregnant women are discussed as well as the dietary content of iron. Both beneficial and adverse effects of iron supplementation are outlined. It is not documented that supplementation has any substantial effect on birth weight or various complications in pregnancy. However, supplementation corrects the iron store and biochemical parameters of iron deficiency including hemoglobin concentration (Hb) and maintains the maternal iron stores in the puerperium. Recent literature also suggests that iron supply to the pregnant women may have beneficial effects on the iron content of neonates the first year of life.

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OBJECTIVE: To study the association between umbilical plasma levels of interleukin-6 (IL-6) in relation to fetal growth in subgroups of preeclampsia, and in control pregnancies. METHODS: Umbilical cord plasma was collected from 12,804 consecutive births. A total of 271 singleton cases of preeclampsia were identified, and classified as mild or severe, and as disease with early or late onset. As controls, 611 singleton pregnancies without preeclampsia were selected, and the ratio between observed and expected birth weight was used as a measure of fetal growth. In the analysis, we also included maternal smoking during pregnancy. Umbilical cord plasma IL-6 concentration was measured with an IL-6 bioassay. Comparing controls with subgroups of preeclampsia (severe and early onset), this study had a statistical power of 90% to detect a difference in cord IL-6 of 10 pg/mL. RESULTS: In severe preeclampsia, cord plasma IL-6 concentration was lower than among controls (P <.001), and there was a sharp decrease in cord plasma IL-6 with decreasing birth weight ratio (P trend <.001). By further dividing the preeclampsia group into early or late onset, the strong association between low IL-6 levels and low birth weight ratio appeared to be present mainly in early-onset disease. These results were not confounded by maternal smoking. CONCLUSION: Restricted fetal growth related to preeclampsia is associated with reduced umbilical cord plasma IL-6 concentration in cases with early-onset disease. In these cases, fetal growth restriction could be mediated by impaired trophoblast function.

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OBJECTIVES: To describe and compare attitudes, knowledge and management strategies concerning the prescription of hormone replacement therapy (HRT) between gynecologists from three Scandinavian countries. DESIGN AND METHODS: In a cross-sectional study gynecologists in Denmark (n=386), Norway (n=475) and Sweden (n=1323) were invited by letter to complete and return an enclosed questionnaire. Then 1653 of the 2184 (76%) contacted gynecologists completed and returned the questionnaire. RESULTS: of the 1653 Scandinavian gynecologists, 42% offered HRT to all women provided there was no contraindication, while 58% recommended HRT to selected women after considering the advantages and disadvantages of HRT. In Norway and Sweden, the proportion of gynecologists routinely prescribing HRT for women without contraindications increased with age and in the oldest age group of gynecologists (>55 years) 49 and 56%, respectively, recommended HRT to all women. The gynecologists were unanimous in their choice of the type of HRT for perimenopausal women as 94% preferred cyclical or sequential combined (estrogen/progestogen) treatment or estrogen monotherapy (orally or transdermally) for hysterectomized women (95%). For postmenopausal women, 75% of the gynecologists offered continuous combined HRT while cyclical combined therapy was chosen by 15% of the gynecologists. No significant differences were found between physicians in the three countries regarding indications and contraindications to HRT. CONCLUSIONS: Scandinavian gynecologists are generally well informed concerning HRT and liberally recommend HRT for women without contraindications.

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OBJECTIVE: To study associations between established risk factors for pre-eclampsia and different clinical manifestations of the disease. DESIGN: A population-based, nested case-control study. SETTING: Information from 12,804 consecutive deliveries that took place over three years at a birth clinic, which alone serves a population of nearly 240,000 in Rogaland county, Norway. SUBJECTS: Cases of pre-eclampsia (n = 323) and healthy controls (n = 650) were selected. Pre-eclampsia was defined as increase in diastolic blood pressure (> or = 25 mmHg to > or = 90 mmHg) and proteinuria (> or = 1+ by dipstick testing) after 20 weeks of pregnancy. MAIN STUDY MEASURES: Parity, previous pre-eclampsia, blood pressure, maternal weight, and maternal smoking were included as study variables. Women with pre-eclampsia were grouped according to clinical manifestations of the disease (i.e. severity [mild, moderate or severe]) and time of onset (early or late gestation). Associations with the study factors were estimated as relative risks (odds ratio, OR). RESULTS: Both nulliparity and hypertension increased pre-eclampsia risk, with no clear preference for any clinical subtype. High maternal weight was related to a higher risk of mild and moderate, but not severe, pre-eclampsia. Previous pre-eclampsia strongly increased the risk for pre-eclampsia in the current pregnancy, and the risk of early onset disease was especially high (OR 42.4; 95% CI 11.9-151.6). Overall, smoking was associated with a reduced risk for pre-eclampsia (OR 0.6; 95% CI 0.4-0.9). However, no effect of smoking was observed in the early onset disease group and among women with repeated pre-eclampsia. CONCLUSION: Nulliparity and hypertension increased the risk for each subgroup of pre-eclampsia, but high maternal weight, previous pre-eclampsia and smoking were not consistently associated with each clinical subtype. This observation may suggest that heterogeneous clinical manifestations of pre-eclampsia may be preceded by different pathological mechanisms.

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OBJECTIVE: To determine if the influence of preeclampsia on birth size varies with clinical manifestations of the disease, and to evaluate whether maternal factors, such as smoking, modify the effect of preeclampsia on fetal growth. METHODS: Among 12,804 deliveries in a population of approximately 239,000 over a 3-year period, 307 live singleton infants were born after preeclamptic pregnancies. We compared those with a sample of 619 control infants. Preeclampsia was defined as increased diastolic blood pressure (BP) (increase of at least 25 mmHg to at least 90 mmHg) and proteinuria after 20 weeks' gestation. Clinical manifestations were classified according to BP and proteinuria into subgroups of mild, moderate, or severe (including cases with eclampsia and hemolysis, elevated liver enzymes, low platelets [HELLP] syndrome) preeclampsia, and according to gestational age at onset, as early or late preeclampsia. Birth size was expressed as the ratio between observed and expected birth weights, and infants smaller than two standard deviations from expected birth weights were classified as small for gestational age (SGA). RESULTS: Preeclampsia was associated with a 5% (95% confidence interval [CI] 3%, 6%) reduction in birth weight. In severe preeclampsia, the reduction was 12% (9%, 15%), and in early-onset disease, birth weight was 23% (18%, 29%) lower than expected. The risk of SGA was four times higher (relative risk [RR] = 4.2; 95% CI 2.2, 8.0) in infants born after preeclampsia than in control pregnancies. Among nulliparas, preeclampsia was associated with a nearly threefold higher risk of SGA (RR = 2.8; 1.2, 5.9), and among paras, the risk of SGA was particularly high after recurrent preeclampsia (RR = 12.3; 3.9, 39.2). In relation to preeclampsia and maternal smoking, the results indicated that each factor might contribute to reduced growth in an additive manner. CONCLUSION: Severe and early-onset preeclampsia were associated with significant fetal growth restriction. The risk of having an SGA infant was dramatically higher in women with recurrent preeclampsia. Birth weight reduction related to maternal smoking appeared to be added to that caused by preeclampsia, suggesting that there is no synergy between smoking and preeclampsia on growth restriction.

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A questionnaire was sent to all 475 members of the Norwegian Gynaecological Society. It was based on a similar study previously performed in Denmark and Sweden. 85% of the members returned the questionnaire. 382 (80%) had answered the questions; 153 (40%) women, 228 (60%) men, and one case where the sex was not stated. The mean age was 48 years (SD 10). The male gynaecologists had a more liberal attitude towards hormone replacement therapy than their female counterparts, 43% of them recommending oestrogen for all women, compared to 31% of the female gynaecologists. The younger doctors were more restrictive in their recommendations but attitudes became more liberal the older the doctors were. Among gynaecologists over 55 years, 49% of males and 50% of females recommended oestrogen for all women. The final decision as to whether or not to take hormone replacement therapy was most often made by the patient herself (61%). The majority of both female (86%) and male (75%) gynaecologists considered risk factors for heart disease to be an indication for oestrogen. In perimenopausal women, 356 (93%) preferred oral cyclical oestrogen combined with progestagen, whereas in postmenopausal women 333 (87%) preferred to take oral oestrogen combined with progestagen continuously.

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In 1997 a questionnaire on hormone replacement therapy was sent to all 475 members of the Norwegian Society for Obstetrics and Gynaecology. There was an 80% response rate. Among the questions asked, were some concerning the members' personal use of hormones. 36 of the 153 female gynaecologists were menopausal or had climacteric complaints. 28 (78%) out of the 36 used oestrogen, four (11%) had contraindications, and another four (11%) were not in need of therapy. Of 228 male gynaecologists 96 had partners who had either climacteric symptoms or were menopausal, and 74 (77%) of these were receiving hormone treatment. The reasons given for not using oestrogen were lack of symptoms requiring therapy in 14 cases (15%) and contraindications in one case (1%). In seven cases (7%) no information was provided. In 1996 about 19% of Norwegian women aged 45 to 69 years used hormone replacement therapy. The use of hormones among female gynaecologists and partners of male gynaecologists is thus four times higher than in the rest of the population.

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This paper describes structure, process, results, and evaluation of the Norwegian Society of Gynaecology and Obstetrics' Guidelines in obstetrics. This work, which lasted for 2 1/2 years, involved almost all obstetrical departments in Norway and 1/4 of all members of the Norwegian Society of Gynaecology and Obstetrics. All members of the Norwegian Society of Gynaecology and Obstetrics were invited to answer 24 questions. Of the 63% who replied to the questionnaire, 44% and 48% respectively stated that the Guidelines in obstetrics were very good or good. The introduction of the Guidelines in obstetrics led to changes in routines in more than 70% of the hospitals, and the different categories of hospital physicians changed their routines as well (55-65%). 83% of the heads of the departments stated that the Guidelines in obstetrics served partly or totally as the model for the obstetrical management guidelines. The evaluation and the experience of this quality assessment handbook serve as perspectives for future work.

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The reports on a higher risk of venous thromboembolism associated with third generation oral contraceptives (OCs) received a great deal of media attention in Norway. The Norwegian Medicines Control Authority recommended restricting the use of third generation OCs. The sale of the only third generation OC in Norway decreased by 73%. The total sales of OCs also decreased by 10%, however, despite a recommendation to change drug rather than stop using OC. During the first six months of 1996, the number of legal abortions in 11 hospitals covering 60% of all legal abortions in Norway increased by 297, or 7%, compared with the same period in 1995. A continuous downward trend in the number of legal abortions during the period 1990-95 has been broken, and replaced by an increase, which could represent a greater risk to women's health than a few cases of venous thromboembolism.

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PIP: Approximately 17% of fertile women in Norway used oral contraception (OC) during 1995. The media in Norway gave considerable coverage during November-December 1995 of recent reports on the risk of venous thromboembolism associated with third generation OC use. Subsequent health authority action against Marvelon, the only third generation OC in Norway containing desogestrel, led to an approximately 75% decline in the product's level of use by late February 1996. Abortion figures were examined from Norway's nine largest hospitals to assess whether the media scare affected the number of abortions in the country. Approximately 50% of all births and abortions in Norway take place in the studied hospitals and all legal abortions are performed in public hospitals. Although the number of abortions per year had declined steadily over the period 1988-94, the number of abortions was up by 5% and 11% in January and February 1996, respectively, compared to the same months one year earlier. The largest increase in any single institution for the 2 months combined was 22%. It remains too early to tell whether the increase in the number of abortions has peaked or if it will continue.^ieng

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Quality assurance is a managerial responsibility, but the medical management itself must also be quality assured. Today quality assurance of medical management is usually performed when the organization is not functioning properly, but quality assurance should be a continuous process. Regular feedback to the management is essential from all levels of the organization. Standards must be established for good medical management. The medical profession must start this work now. There are many others who want to take it over.

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In this study, perinatal data from 73 children with sudden infant death syndrome (SIDS) and 73 matched controls were compared. Birthweight, length and circumference of the head were significantly smaller in cases of SIDS. The odds ratio for SIDS when mothers who had smoked 1-10 cigarettes per day were compared with non-smokers was 2.3 (95% confidence interval: 1.0-5.7). The odds ratio was 6.2 (95% confidence interval: 2.8-14.1) when the mother had smoked more than ten cigarettes daily during pregnancy. Approximately 40% of all pregnant women still smoke during pregnancy. The challenge is to pass on this information in a proper way in order to reduce/stop smoking during pregnancy.

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Forty-seven boys born by cesarean section in 1962-63 were re-examined 18 years afterwards, at the military medical draft board. No significant increase in mortality or morbidity was found. The mean general intelligence was significantly lower when placenta praevia had been the reason for abdominal delivery. In these cases the infants had had a lower birthweight and placental weight, on average, than the other subgroups.

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